Tag: Health Finance

CMS Releases Medicare 2025 Outpatient Prospective Payment System Proposed Rule

Member News

The Centers for Medicare & Medicaid Services (CMS) recently released a proposed rule to update the Medicare fee-for-service outpatient prospective payment system (OPPS) effective Jan. 1,  2025.

The proposed rule:

  • Provides a net 2.3% increase to the OPPS conversion factor from $87.38 to $89.38 for hospitals that report quality measure data.
  • Increases the outlier fixed-dollar threshold by 3.2% from the current $7,750 to $8,000.
  • Modifies the timeframe for standard review of prior authorization requests for hospital outpatient department services from 10 business days to seven calendar days.
  • Uses 2023 claims data and the most updated cost report data from the healthcare cost report information system, primarily from 2022, to set payment rates.
  • Adds three services (CPT codes 0894T, 0895T and 0896T) for liver allograft-related procedures to the 2025 Inpatient-Only List.
  • Updates the core based statistical areas used to determine a hospital’s wage index, consistent with other 2025 proposed rules.
  • Adds two new status indicators (H1 and K1) to identify healthcare common procedure coding system/current procedural terminology (HCPCS/CPT) codes representing separately payable, non-opioid post-surgical pain management products as authorized by the Consolidated Appropriations Act of 2023.
  • Establishes separate payment for diagnostic radiopharmaceuticals with a per-day cost exceeding $630.
  • Excludes qualifying cell and gene therapies from comprehensive ambulatory payment classification packaging.
  • Adopts three measures related to health equity for the Outpatient, ambulatory surgical center (ASC) and rural emergency hospital quality reporting programs, and extending voluntary data reporting for two hybrid measures in the inpatient quality reporting program.
  • Establishes new conditions of participation for hospitals and critical access hospitals focused on obstetrical services and maternal care.
  • Extends the virtual direct supervision of therapeutic and diagnostic services under the physician fee schedule (PFS) through Dec. 31, 2025. The CMS also proposes to extend virtual direct supervision under the OPPS through Dec. 31, 2025, to maintain alignment between the PFS and OPPS.
  • Adds 20 medical and dental procedures to the ASC covered procedures list.
  • Updates the hospital outpatient quality reporting program requirements.
  • Updates requirements for the rural emergency hospital quality reporting program.

The MHA will provide a hospital-specific impact analysis within the next few weeks and encourages members contact Vickie Kunz by Aug. 30 regarding issues identified. Hospitals are encouraged to review the proposed rule and its impact on operations and submit comments to the CMS by Sept. 9.  The CMS is expected to release a final rule around Nov. 1 for the Jan. 1, 2025, effective date.

Members with questions may contact Vickie Kunz at the MHA.

2025 Medicare Fee-for-Service Home Health Proposed Rule Released

Member News

The Centers for Medicare & Medicaid Services (CMS) recently released a proposed rule to update the home health (HH) prospective payment system (PPS) for calendar year (CY) 2025. The rule includes updates to the Medicare fee-for-service HH PPS payment rates based on changes by the CMS and those previously adopted by Congress.

Highlights of the proposed rule, which takes effect Jan. 1, 2025, include:

  • A negative 4% adjustment to base payment rates to achieve budget neutrality following the transition to the Patient-driven Groupings Model (PDGM).
  • A 30-day standard payment rate of $2,008.12 ,down 1.5% from the current $2,038.13, for HH agencies that submit the required quality data.
  • Updating core-based statistical areas for wage index purposes, consistent with recent fiscal year 2025 proposed rules.
  • Recalibrating the PDGM case-mix weights, low utilization payment adjustment thresholds, functional levels and comorbidity adjustment subgroups.
  • Revising the fixed dollar loss ratio from 0.27 to 0.38, reducing outlier payments.
  • Requiring HH agencies to report four new patient assessment items in the HH agency Outcome and Assessment Information Set under the social determinants of health category, beginning CY 2027.
  • Adding a new standard within the Medicare Conditions of Participation requiring HH agencies to develop, implement and maintain a patient acceptance to service policy that is applied consistently to each prospective patient referred for HH care.
  • Requiring long-term care facilities to report respiratory illness data as part of their infection prevention and control programs. The CMS proposes that facilities would electronically report weekly data on COVID-19, influenza and RSV in a standardized format through the National Healthcare Safety Network.
  • Requesting information on:
    • HH quality reporting program measure concepts under consideration for future years.
    • Future performance measure concepts for the expanded HH value-based purchasing model.
    • Rehabilitative therapists conducting the initial and comprehensive assessment.
    • Plan of care development and scope of services HH patient receive.

Members are encouraged to review the proposed rule and contact Vickie Kunz by Aug. 19 regarding issues. Comments are due to the CMS Aug. 26, 2024, and can be submitted electronically. The MHA will provide an estimated impact analysis in the near future.

Members with questions should contact Vickie Kunz at the MHA.